Hundreds Warned of Dirty Endoscope Risk at Air Force Academy Clinic


A bungled cleaning procedure for medical equipment at a clinic shared by the Department of Veterans Affairs and the Air Force Academy could put 267 patients at risk for hepatitis or human immunodeficiency virus.

The VA announced the problem Wednesday afternoon, saying an airman at the clinic skipped a step in cleaning gastrointestinal endoscopes. While the cleaning problem was identified more than a week ago, the agency and the Air Force began notifying patients of the issue on Wednesday, VA spokesman Daniel Warvi said.

"Starting today at noon, I have two specially trained nurses they are calling all of the 61 affected veterans," Warvi said.

The Air Force Academy said its 206 patients were also getting calls. Endoscopy procedures, used to check the digestive tract for abnormalities, had been canceled.

The cleaning issue was traced back to June and continued through September, the academy said.

Warvi said the airman charged with cleaning the hose-like devices skipped a "precleaning" step.

"We would advise that the risk is very low," he said.

The academy said the 19 scopes involved "were thoroughly checked and found to be free of any infectious material." The school admitted that some risk of disease transmittal remains.

Endoscopes were the subject of a Food and Drug Administration warning issued last year after it was found that improper cleaning of the devices can spread disease.

Earlier this year, the University of Colorado Hospital in Denver blamed a dirty endoscope for infections in nine patients, including three who died.

"These patients were very ill, and it is unclear what impact the infections had on their deaths," the hospital said.

VA said, so far, no infections have been tied to the dirty endoscopes at their joint clinic.

The clinic was opened five years ago after the Air Force and VA agreed to pool resources in the Pikes Peak region. In addition to endoscopy, the clinic at the Air Force Academy offers day surgeries and other services to veterans, airmen and family members.

The academy didn't immediately respond to questions about its investigation into the cleaning problem, including whether criminal investigators are involved. It's unclear whether the airman who skipped the cleaning step faces discipline.

The school's top medical officer issued a statement.

"While the risk to the potentially impacted patients is very low, it cannot be discounted entirely," said Col. Walter Matthews, Air Force Academy command surgeon. "Maintaining patient safety and quality is our top priority. We take any potential risk to patient safety very seriously and are committed to informing those under our care of any increased risk."

The VA and the academy said the agencies have reviewed cleaning procedures and are retaining workers.

"The VA Eastern Colorado Health Care System is proud to have a patient safety program that finds and responds to this kind of situation, and we regret and sincerely apologize for any worry or inconvenience this may cause our veterans," VA said in an email.

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